Cognitive loss and hearing loss

Did you know…

There is a clinically significant association between hearing loss and cognitive decline. Individuals with hearing loss demonstrate an accelerated rate of cognitive decline and an increased risk for cognitive impairment1.

The potential mechanisms behind this relationship between hearing loss and cognitive loss, in particular the increased risk for incident dementia2, remain to be determined. Possible rationales for this association may include increased social isolation, changes to the brain, and/or a common process that is influencing both hearing and cognitive functioning in older individuals.

Below you will find some issues that may be common in your practice, some implications for assessment, and some suggestions for solutions you can implement to ensure that you are providing your patients with the best care possible.

Issue

Implications for Cognitive
Assessments and Treatment

As individuals age, they may experience changes in their auditory processing and/or cognitive abilities.

These changes may lead older individuals to require additional time to process and understand the sounds they hear3.

Ensure ample time for your assessments in order to maximize your patient’s ability to understand your questions, instructions, and/or important information you are sharing with them. Encourage patients to ask for repetitions.

If possible, involve a family member.

Provide patients with written instructions (e.g., take your Metoprolol with food or just after eating) that they can refer to at home.

People with hearing loss may be hesitant to seek help.

The average time between an individual noticing a hearing loss and seeking help is 10 years4.

Do not assume that, simply because your patient does not own hearing aid(s), they do not have trouble hearing you.

There are a few simple questions you can ask to screen for hearing loss, e.g., “Do you find that you have to ask people to speak up?”; “Do you have to increase the volume on the radio or television in order to understand what is being said?”; “During conversations, does it sound like other people are mumbling?”; “Is it difficult for you to follow conversations when in a noisy restaurant?”

Consider investing in a personal amplification system, such as a “Pocketalker” to use during your appointments.

If you have a question about your patient’s hearing, refer them to an Audiologist. Appointments are often covered under provincial health care systems (for example, in Ontario, hearing tests are paid for by OHIP).

Cognitive testing (e.g. the MMSE, the MoCA) often relies heavily on an individual’s ability to hear and respond to questions and instructions given5.

Not taking hearing loss into account may result in an inaccurate assessment of cognitive ability.

Patients may not hear test questions and/or may not understand test instructions. This may result in an artificially low score on the cognitive test, which could in turn lead to over-estimation of the individual’s level of cognitive impairment.

Test patients in a quiet room, and ensure that the volume of your voice is appropriate. Consider using a personal amplification device.

Refer your patient to an ENT if they complain of ear pain or a plugged/fullness sensation; they may have cerumen (ear wax) build-up. Removal of cerumen can improve performance on measures of both hearing and cognition6,7.

Behavioural symptoms (e.g. repetition, agitation) that are commonly attributed to the individual’s cognitive loss, may be related to and/or exacerbated by hearing loss.

When individuals with cognitive loss present to a clinic, many of their symptoms overlap with behaviours related to hearing loss. For example, decreased speech understanding, increased requests for repetition, short-term memory problems, and difficulty following conversations may all be related to either hearing and/or cognitive loss.

Physicians may not automatically consider hearing loss as a factor in these symptoms.

At later stages of cognitive loss, behavioural symptoms such as agitation, wandering, and hallucinations may be related to disruptions in auditory processing.

Ensure that clients who own hearing aids are wearing them, that the wax guard in the aids is clear, and that the batteries are working.